🛡️ 安全与感染预防 · 第3课，共6课 · 7 min
约束：最后手段、限时医嘱、快速解开的绳结
Restraints: Last Resort, Timed Orders, Quick-Release Knots
⛓️ 约束是一种医疗干预，其规则比大多数药物还多，管束也更严。一张PRN医嘱、一个系在床栏上的绳结、一次漏查，你就答错了这道题，还可能伤害患者。
⛓️ A restraint is a medical intervention with more rules than most medications, and a shorter leash. One PRN order, one knot on a side rail, one missed check, and you have failed the question and possibly injured the client.
💡 核心要点
先用限制性最小的方法，要有非PRN的限时医嘱，用快速解开的绳结系在床架上，频繁检查，每两小时松开一次，并在安全后尽快解除。
Least restrictive first, a timed non-PRN order, quick-release knot to the frame, frequent checks, release every two hours, and off as soon as safe.
🧠 为什么重要
约束是最后手段，要在限制性较小的措施失败后才使用：重新定向、陪护人员、床边报警器、把患者移到靠近护士站的位置、治疗疼痛或躁动的原因。必须有医务人员的医嘱；在紧急情况下，护士可以先实施约束，随后必须立即补开医嘱，对暴力或自毁行为的约束还需要在一个小时内进行面对面评估。约束医嘱绝不允许写成PRN。针对暴力或自毁行为的医嘱必须按时续开：成人每4小时一次，每2小时一次适用于9至17岁者，9岁以下儿童每小时一次；非暴力性医疗约束的医嘱按医院政策续开，通常为每个日历日一次。用快速解开的绳结把约束带系在床架上，绝不能系在床栏上，并确保约束带与患者皮肤之间能容纳两根手指。经常检查血液循环、皮肤和感觉，通常按政策每15到30分钟一次；至少每2小时松开并重新摆好体位一次，提供饮水和如厕协助，并记录行为、尝试过的替代措施、患者的反应和每次检查。行为一消失，就立即解除约束。
Restraints are a LAST RESORT after less restrictive measures fail: reorientation, a sitter, a bed alarm, moving the client near the station, treating pain or the cause of agitation. A provider's ORDER is required; in an emergency the nurse may apply restraints and must obtain the order immediately afterward, and restraint for violent or self-destructive behavior also needs a face-to-face evaluation within one hour. PRN restraint orders are never allowed. Orders for violent or self-destructive behavior must be renewed every 4 hours for adults, every 2 hours for ages 9 to 17 and every hour for children under 9; orders for non-violent medical restraints are renewed as hospital policy sets, commonly every calendar day. Tie restraints with a QUICK-RELEASE knot to the BED FRAME, never the side rails, and make sure two fingers fit between the restraint and the client's skin. Check circulation, skin and sensation often, commonly every 15 to 30 minutes per policy; release and reposition at least every 2 hours, offer fluids and toileting, and document the behavior, alternatives tried, the client's response and each check. Remove the restraint as soon as the behavior resolves.
🏥 真实场景
🛏️ 一名意识混乱的患者拉扯自己的IV管路。护士尝试用套筒遮住穿刺部位，把IV输液泵移出视线，打电话请家属来陪坐，并请医务人员复核镇静药物。这些都不是约束。在使用手套式约束或腕部约束之前，应先尝试这类限制性较小的措施，并把尝试过的措施记录下来。
🛏️ A confused client pulls at his IV. The nurse tries covering the site with a sleeve, moves the IV pump out of view, calls a family member to sit, and asks the provider to review the sedating medication. None of that is a restraint. Less restrictive steps like these should be tried first, and the ones tried should be documented, before a mitt or wrist restraint is used.
📌 要点总结
- 先用替代措施；约束是最后手段；绝不PRNAlternatives first; restraints last; never PRN
- 暴力约束续开：成人q4h，q2h适用于9–17岁，q1h适用于9岁以下Violent restraints: renew q4h adults, q2h ages 9–17, q1h under 9
- 快速解开的绳结系在床架上；经常检查，每2小时松开一次Quick-release knot to the bed frame; check often, release every 2 hours
📖 本课术语
约束 (Restraint): 任何限制活动或管理行为、且不是患者病情标准治疗的人工方法、物理装置或药物；它是最后手段，需有有时限、非PRN的医嘱。
快速松解结 (Quick-release knot): 一种一拉就能解开约束的结，系在床架上，绝不系在床栏上。
✅ 自我测试
哪份约束医嘱可以接受？Which restraint order is acceptable?
- “因拉扯管路使用双侧软腕部约束；按政策续开”'Bilateral soft wrist restraints for pulling at lines; renew per policy'
- “因躁动PRN使用软腕部约束”'Soft wrist restraints PRN for agitation'
- “软腕部约束24小时，按需使用”'Soft wrist restraints for 24 hours as needed'
- 口头医嘱：“只要家属离开病房就使用软腕部约束”A verbal order to apply soft wrist restraints 'whenever the family leaves the room'
答案: A · “因拉扯管路使用双侧软腕部约束；按政策续开”
可以接受的约束医嘱要写明约束的类型和它所针对的具体行为，要有时间限制，且绝不能是PRN。对于非暴力性医疗约束，时间限制就是医院政策规定的续开间隔，通常为每个日历日，因此“按政策续开”使该医嘱有了时间限制。PRN或“按需”的医嘱，或者与“只要家属离开病房”这类条件挂钩的医嘱，都绝不能接受，写上“24小时”也不能让一份“按需”医嘱变得可以接受。
An acceptable restraint order names the type of restraint and the specific behavior it addresses, is time-limited and is never PRN. For non-violent medical restraints, the time limit is the renewal interval set by hospital policy, commonly each calendar day, so 'renew per policy' makes the order time-limited. Orders that are PRN or 'as needed', or tied to a condition such as 'whenever the family leaves the room', are never acceptable, and stating '24 hours' does not make an 'as needed' order acceptable.
护士应把腕部约束的系带固定在哪里？Where should the nurse secure the ties of a wrist restraint?
- 用快速解开的绳结系在床架上To the bed frame with a quick-release knot
- 用快速解开的绳结系在患者的病号服上To the client's gown with a quick-release knot
- 系在床栏上，方便工作人员够到To the side rail where staff can reach it easily
- 用双平结系在床头板上To the headboard using a double square knot
答案: A · 用快速解开的绳结系在床架上
系带要系在可移动的床架上，这样升降床栏就不会勒紧约束带，而且要使用能立即解开的绳结。
Ties go to the movable bed frame so that raising or lowering a rail cannot tighten the restraint, using a knot that releases instantly.
一名被约束了3小时的患者出现手部发凉、苍白，毛细血管再充盈减弱，首要行动是什么？A client in restraints for 3 hours has a cool, pale hand with weak capillary refill. What is the priority action?
- 记录这一发现，2小时后复查Document the finding and recheck in 2 hours
- 松开或解除约束并评估血液循环Loosen or remove the restraint and assess circulation
- 在约束带上热敷Apply a warm compress over the restraint
- 在触碰约束带之前通知医务人员Notify the provider before touching the restraint
答案: B · 松开或解除约束并评估血液循环
血液循环受损是迫在眉睫的安全问题。解除约束，进行评估，然后通知。
Impaired circulation is an immediate safety problem. Release the restraint, assess, then notify.
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